Archive of SID

Health Education and Health Promotion. 2018;6(1):9-16

Correlation between Maternal Health Literacy and Dietary Self-Efficacy in Pregnant Mothers

A R T I C L E I N F O A B S T R A C T Aims Health literacy becomes increasingly important in the prenatal Article Type of risk by pregnant women. Maternal understanding of and perception of risk may have an Descriptive Study impact on mothers’ willingness to follow antenatal recommendations. This study aimed at

Authors mothers. Kharrazi S.S. 1 MSc, Instrumentsinvestigating correlation & Methods between In this maternal cross-sectional health literacydescriptive-analytical and dietary self-efficacy study, 120 in pregnant Peyman N.* PhD, mothers were selected from health centers in Mashhad city, Iran in 2016. The subjects were Esmaily H.2 PhD selected through multi-stage cluster random sampling method. Data were collected using Maternal Health Literacy and outcomes Questionnaire and Perceived Dietary

descriptive statistics (mean, standard deviation, and frequency) and analytical statistical tests How to cite this article (independentSelf-efficacy Questionnaire. t-test, ANOVA, The Turkey’s obtained Post data hoc testwere and analyzed Pearson by correlation SPSS 15 software test). and using Kharrazi S S, Peyman N, Esmaily Findings H. Correlation between Maternal Health Literacy and Dietary Self- in Pregnant Mothers. He- maternal healthThere literacywas a positive and educational and significant level, incomes, correlation and between living place maternal (p<0.05). health But literacydietary alth Education and Health Prom- and dietary self-efficacy (r=0.29; p=0.001). Significant relationships were found between otionEfficacy Conclusion self-efficacy had only a significant relationship with incomes (p<0.05). . 2018;6(1):9-16. There are the significant correlation between maternal health literacy and self- Keywords Health Literacy Pregnant Women Diet efficacy in pregnant mothers. ; ; ; Self-Efficacy

C I T A T I O N L I N K S

[1] Barriers to diabetes management: Patient and ... [2] Assessing the effect of educational program ... [3] The relationship between health literacy ... [4] Health literacy: Concept ... *“Health Science Research Center” [5] Improvement in maternal health literacy ... [6] Associations between maternal health and “Health Education & Health Promotion Department, Public ... [7] The effect of education on nutrition behavioral ... [8] Investigating health Health School”, Mashhad University literacy in ... [9] Health literacy levels of diabetic patients referred ... [10] Individual of Medical Sciences, Mashhad, Iran [11] The relationships between perceived nutritional 1“Student Research Committee” and “School of Health”, Mashhad Univer- ... [12] Breaking it down’: Patient-clinician communication ... [13] Clinical obstetric sity of Medical Sciences, Mashhad, outcomesdeterminants related of fish to consumption continuity ...... [14] Brief questions to identify patients with ... [15] Iran Health literacy: A policy challenge for ... [16] 2“Health Science Research Center” and “Biostatistics Department, Pub- healthy ... [17] An evaluation of the validity and reliability ... [18] Health Literacy among lic Health School”, Mashhad Univer- in ... [19] Determination of knowledgeInfluence and health of maternal... [20] Health health Literacy literacy and on sity of Medical Sciences, Mashhad, Utilization of ... [21] Health literacy and its relationship with ... [22] Study of health literacy Iran level of women ... [23] Relationship between health literacy ... [24] Health literacy and pregnancy preparedness ... [25] Correspondence [26] Assessing adult health literacy in urban ... [27] Address: Health Education & Health Survey influencing factors on in ... Promotion Department, Public [28] Functional health literacy among primary ... [29] Evaluation of health literacy of ... Health literacy and the influencing ... Health School, Mashhad University [30] Performance of a Brazilian population ... [31] Associations between health literacy ... of Medical Sciences, Shahid Fakoori [32] Health literacy and its association ... [33] Preparing for an epidemic of limited ... Boulevard, Javan Square, Mashhad, [34] Effects of health literacy on health ... [35] The prevalence of limited ... [36] The Iran Phone: +98 (51) 38544643 Fax: +98 (51) 38517505 admitted to Gorgan ... [37] The relationship between health literacy ... [38] The association [email protected] ofrelationship health literacy between ... [39] health The relationship literacy and between self-efficacy health in ... patients [40] Health with literacy type II diabetespredicts [41] Communicative and critical health Article History literacy and self-care behaviors in patients ... [42] The mechanisms linking health literacy Received: September 5, 2017 tochange behavior in physical and health activity ... self-efficacy[43] Association among between ... maternal health literacy level with Accepted: December 15, 2017 pregnancy care and its ... ePublished: February 1, 2018 Copyright© 2018, TMU Press. This open-access article is published under the terms of the Creative Commons Attribution-NonCommercialwww.SID.ir 4.0 International License which permits Share (copy and redistribute the material in any medium or format) and Adapt (remix, transform, and build upon the material) under the Attribution-NonCommercial terms. ArchiveCorrelation of SID between Maternal Health Literacy and Dietary Self-Efficacy in Pregnant Mothers 10 Introduction establishment and maintenance of health Health literacy is the result of an effort to behaviors. Therefore, it can be a used for promote social and individual factors, facing promoting health, education, and adherence health literacy concerns and dimensions, and to various dietary regimens [1]. Self-efficacy is recognized as vital to health care outcomes theory cares about the role of self-confidence and consequences [1-3]. It is essential to in performing desired behaviors. Perceived empower for individuals to change their self-efficacy is an important predictor of the behavior and lifestyle to improve their health intent and ability to accept health patterns [8]. and quality of life [4]. Health literacy in Moreover, self-efficacy is used as an essential pregnant mothers means special component in health research and in the and particular social skills to diagnose etiology of health and disease. Self-efficacy is prenatal risk symptoms, healthy lifestyle and known as an important predictor of behavior proper nutrition during pregnancy. It change in managing nutritional habits, influences pregnancy by improving the quality smoking cessation and weight control. Self- of prenatal care. Mothers with high health efficacy is a basic structure of Bandura's social literacy tend to have low birth weight , cognitive theory and reflects the individual's early birth, and fewer neonatal [5]. self-confidence in being able to adopt and Hence, side effects appear to be occurring perform a special behavior [9]. Therefore, the more in women with poorer health literacy. study and recognition of predictive variables Maternal health literacy is a skill to diagnose of health in promoting healthy behaviors of pregnancy risk symptoms. Having a healthy women in childbearing age can be a step lifestyle and proper diet during pregnancy is a forward in improving maternal health and [7] positive factor in the health of the mother [5]. pregnancy outcomes . Over the past few Therefore, although it is essential to talk about decades, healthy behaviors have been strongly the topics and give information regarding promoted for healthy food, but the desire and pregnancy, what is important is the level of ability to adopt a healthy lifestyle and change understanding, awareness, and the ability to people's behavior towards these healthy use this information in cases of necessity and behaviors is a complex issue [10]. The mother's risk. Therefore, there is a need for diet is effective both on maternal and fetal comprehensive efforts to increase maternal health. Nutritional behaviors affect mother's health literacy [6]. Before and during weight gaining during pregnancy and having a pregnancy, education on nutrition and healthy baby. Getting insufficient nutrition counseling women of childbearing age can be and supplements during pregnancy can result an ideal opportunity for regulating the daily in inappropriate condition for , such as consumption of iron and folic acid by them. In low birth weight and delayed physical and the health education, theory predicts the mental growth. Understanding nutritional consequences of programs, and provides a status and dietary self-efficacy can change the framework for educational intervention diet of pregnant women, which benefits the planning that helps us to analyze success or mother and the baby. Increased awareness of failure [7]. According to done studies, one of pregnant women, nutritional anemia can be the most famous theories about how to reduced by having a healthy diet, and predict and describe behaviors is the “Theory subsequently, preventing low birth weight [11]. of Self-efficacy”, which is used in behavior Low skilled and low literate women began change. Bandura describes it as a person's their pregnancy later, and their admittance judgment of his/her ability to act. It is clear was inadequate [12]. Prenatal care during when people believe capable of acting pregnancy has reduced fetus mortality, low effectively, they are more likely to perform birth weight, and increased maternal weight particular behavior. A person with low self- gain during pregnancy [13]. Since identifying efficacy is less likely to try on new health people with inadequate health literacy is very behaviors or change the behavioral habits. In important and health care providers are often fact, a strong sense of self-efficacy is weak in this regard, identifying these people associated with health promotion [1]. with low levels of health requires specific Empirical evidence from studies also supports methods [14]. To increase the level of people's the relationship between self-efficacy and the health literacy, using approaches such as Health Education and Health Promotion Winter 2018, Volume 6, Issue 1 www.SID.ir Archive of11 SID Kharrazi S.S. et al. streamlining information can be helpful. data. In the demographic information section, However, it has been shown that the use of such as questions about the age of the mother communication strategies and getting and the spouse, the level of mother and wife's assistance from health education education, the mother's and the spouse's job, professionals to plan and design useful and and the level of family income, as well as effective programs tailored to the target information on pregnancy, including the first groups and their skill levels are efficient as day of the last pregnancy (LMP), pregnancy well. They should choose the best educational age, current complaints, voluntarily or approach to be able to make the best involuntarily pregnancy, laboratory improvement in the level of health literacy information (hemoglobin level, weight, BMI), that is a very important and vital etc. were asked from each mother. MHLAPQ issue [15]. was used to measure maternal health literacy Hence, health literacy is very important in [16, 17]. This questionnaire has 25 questions. mothers who play an important role in Each mother answered to the questions with promoting the health of the whole community strongly agree, agree, disagree, and and family, and it has a direct impact on the completely disagrees. Validity and reliability performance or nonperformance of health of MHLAPQ have been confirmed by Karazi et behaviors, al. [17]. This study aimed at investigating correlation PDSEQ (Demographic questionnaire, between maternal health literacy and dietary perceived dietary self-efficacy self-efficacy in pregnant mothers. questionnaire): Perceived PDSEQ was used to determine the level of self-efficacy of Instruments and Methods pregnant mothers [11]. The questionnaire This is a cross-sectional descriptive-analytical consisted of 20 items including questions study that it was conducted on 120 pregnant related to the quality of diet (10 items), women who were covered by health centers supplementary diet (6 items) and prohibited in Mashhad City, Iran in 2016. The sample size diet (4 items). The quality of a diet is a normal was determined with a 95% confidence balanced diet that is sufficient for adequate interval and 80% test power, using the growth and proper nutrition in the fetus and formula for estimating the mean of a the pregnant mother. Supplements include quantitative variable. The subjects were iron supplementation and folic acid. The selected through multi-stage cluster random prohibited diet is the food, which is harmful to sampling. To access the research samples, the mother and the . The Likert 5-point four clusters were randomly selected from the scale was used to answer the questions, and five health centers of Mashhad. Then, from all 20 items were expressed as positive. The each cluster, four health centers were selected minimum and maximum scores were 20 and randomly (a total of 16 health centers). 100 in this questionnaire, respectively [11]. Finally, by referring to the health centers and Cronbach's alpha coefficient was 0.89 in the examination of the families cases, the health literacy questionnaire and 0.91 in the pregnant mothers who had conditions for perceived dietary self-efficacy questionnaire. participation in the study were randomly Repeat test results showed the stability of the selected., they were asked to refer to the questionnaire and subcategories. Duration of health center to fill in the questionnaire by data collection was three months. telephone. Entry criteria were mothers with a Mothers participated in the study after newborn and willing to participate in the knowing the purpose of the study and study. The exit criteria included completing the consent form. To observe from chronic illnesses, presence of high risk ethical issues, coded, confidential, and conditions during pregnancy, and lack of unnamed questionnaires were used. education in medical sciences. Data analysis was performed using SPSS 15 Two questionnaires were used as a tool in this software and analytical tests. Independent t- research: test was used to examine the relationship MHLAPQ (Maternal health literacy and between quantitative and qualitative pregnancy outcomes questionnaire): variables, ANOVA and Tukey’s tests for MHLAPQ was used to collect the required comparison of the means of more than two Health Education and Health Promotion Winter 2018, Volume 6, Issue 1 www.SID.ir ArchiveCorrelation of SID between Maternal Health Literacy and Dietary Self-Efficacy in Pregnant Mothers 12 variables, and Pearson’s correlation to There was a positive and significant determine the correlation of quantitative correlation between maternal health literacy variables with each other at the 95% and 99% and dietary self-efficacy (r=0.29; p=0.001). significance levels. Self-efficacy improves the health literacy of pregnant mothers. Findings However, there was no significant The mean age of mothers was 27.2±5.1 years. relationship between the mother’s and The minimum age for mothers was 14 years spouse’s age with maternal health literacy and and the maximum age was 42 years. The mean dietary self-efficacy. There was no significant age of Husband was 31.7±5.8 and the relationship between maternal health literacy maximum age was 50 years. (p=0.42) and job, but there was a significant 84.2% of their spouses were self-employed, relationship with educational level (p<0.001), 7.5% were unemployed and 8.3% were place of living (p=0.001) and household employees of government departments. In income (p=0.008). terms of economic indicators, only 22.2% of There was difference between the average them had an income of higher than 10 million level of health literacy and the level of Rials, while others had lower incomes education in those who had university (table1). education compared to the rest of the groups. The average level of health literacy was higher in people with higher education than in other Table1) Distribution of Absolute and relative frequency in the samples (120 people) groups. Variable Number Percent The mean of self-efficacy was 86.2±11.8 in Education mothers with a monthly household income of Elementary 30 25.0 Junior high school 31 25.8 more than 10 million Rials, and the difference High school diploma 41 34.2 was significant (p≤0.05). The level of College educated 18 15.0 education, occupation and place of residence Occupation Housewife 116 96.7 were not significantly correlated with dietary Employed 4 3.3 self-efficacy, but this difference was Location significant in the family’s monthly income City 65 54.2 Village 55 45.8 (Table 2). Variables related to pregnancy such as the The average self-efficacy of mothers was number of , the number of alive 80.1±12.4, with a minimum self-efficacy of 40 children, the birth weight of the baby, the and a maximum of 100. The average maternal onset of care, the number of cares during health literacy rate was 42.5±7.6 in MHLAPQ pregnancy, the use of ferrous sulfate, the use with a minimum of 21 and a maximum of 56. of multivitamin supplementation and anemia

Table 2) Comparison of Statistical Averages of maternal health literacy and dietary self-efficacy with respect to demographic characteristics in the samples (120 people) Maternal health Dietary self- Variable Test statistic & p-value Test statistic & p-value literacy efficacy Level of Education Elementary 38.9±8.1 80.6±11.4 Junior high school 42.6±6.3 F=6.812 77.3±13.0 F=1.186 High school diploma 42.4±7.0 p<0.001 80.2±11.3 P=0.318 College educated 48.4±6.6 48.1±14.9 Occupation Housewife 42.5±7.4 t=0.792 46.5±6.6 t=0.071 Employed 39.5±12.5 p=0.43 42.5±15.2 p=0.088 Location City 45.0±6.2 t=4.387 81.1±12.2 t=0.958 Village 39.4±8.0 p<0.001 78.9±12.6 p=0.340 Health Education and Health Promotion Winter 2018, Volume 6, Issue 1 www.SID.ir Archive of13 SID Kharrazi S.S. et al. had significant statistical relationships with two deliveries, more than three children, six maternal health literacy (p<0.05), but there times care or more and referred to the health was no relationship with the history of centers in the second semester of pregnancy (P=0.924). In examining the for the first time. The rest had no difference. difference between the average health literacy Regarding the mean of dietary self-efficacy, rate and the number of pregnancies, the there was a statistically significant number of alive children, the onset of care and relationship with supplemented ferrous the number of cares during pregnancy, this sulfate (p=0.001), multivitamin difference was related to those mothers who supplementation (p<0.001) and anemia had more than three pregnancies, more, than (p=0.007; table3).

Table 3) Comparison of Statistical Averages of pregnancy-related variables with nutritional self-efficacy and maternal health literacy (120 people) Number Maternal health Test statistic & Dietary Test statistic & p- Variable (Percent) literacy p-value self-efficacy value Gravidity 1 36 (30) 81.6±13.5 44.7±7.8 F=0.440 F=3.442 2 48 (40) 70.0±12.7 42.4±7.7 P=0.645 P=0.035 ≥ 3 36 (30) 80.1±10.8 40.1±6.6 Abortion history Yes 24 (20) 79.6±11.2 t=0.246 42.6±5.9 t=0.096 No 96 (80) 80.3±12.7 p=0.806 42.4±7.9 p=0.924 Birth weight <2500gr 6 (5) 78.0±7.9 t=-0.433 27.33±4.8 t=-5.630 ≥2500gr 114 (95) 80.2±12.6 p=0.666 43.2±6.8 p<0.001 Number of live children 1 44 (36.7) 82.3±13.2 45.7±7.5 F=2.183 F=4.901 2 47 (39.1) 77.3±12.5 41.8±8.1 P=0.117 P=0.009 ≥ 3 29 (24.2) 81.5±10.1 39.6±6.5 Beginning of prenatal care First 3 semester 74 (61.7) 80.7±12.3 44.9±6.9 F=0.438 F=12.543 second 3 semester 41 (34.1) 78.8±12.6 38.4±7.1 P=0.646 p<0.001 Third 3 semester 5 (4.2) 82.8±13.7 38.8±6/2 Multivitamin supplements Yes 84 (70) 83.0±11.0 t=4.171 45.3±5.9 t=7.630 No 36 (30) 73.4±12.9 p<0.001 35.8±7.5 p<0.001 Number of cares during pregnancy <5 25 (20.8) 36.6±7.5 36.6±7.5 F=1.337 F=15.920 5 21 (17.5) 40.3±5.5 40.3±5.5 P=0.267 p<0.001 ≥ 6 74 (61.7) 45.0±6.8 45.0±6.8 Ferrous sulfate supplementation Yes 90 (75) 82.3±11.3 t=3.515 44.5±6.1 t=5.843 No 30 (25) 73.6±13.4 p<0.001 36.3±8.1 p<0.001

Discussion difference regarding the people with In the present study, considering the university education. However, there was no relationship of health literacy and self-efficacy significant relationship with dietary self- with demographic characteristics, based on efficacy. Maternal occupation had just a the results of Spearman's correlation significant relationship with maternal health coefficients, there was no significant literacy. Family monthly income showed a relationship between the mother’s and significant relationship with all the variables. father's age, maternal health literacy and The place of living had a significant dietary self-efficacy. According to the results relationship with maternal health literacy but of the one-way ANOVA and independent not correlated with dietary self-efficacy. sample t-test, there was no significant In the study of Javadzadeh et al. entitled relationship between maternal education "Adult Health Literacy in Isfahan", there was a and maternal health literacy. There was a significant relationship between health

Health Education and Health Promotion Winter 2018, Volume 6, Issue 1 www.SID.ir ArchiveCorrelation of SID between Maternal Health Literacy and Dietary Self-Efficacy in Pregnant Mothers 14 literacy level and age, educational level, literacy and knowledge in people with higher gender and economic status, so that educational level confirms the role of inadequate health literacy was observed in education in this regard [2]. The findings of this older people with less education, women and study confirm this, and show that mothers the low income group [18]. In his study titled with university education had significantly "Health awareness and health status in type 2 higher health literacy than other groups; other diabetic women referring to hospitals studies have achieved similar results [12, 24, 30- affiliated to Tehran University of Medical 33]; however, it is not consistent with the Sciences, Tal associated health literacy with results by Kohan et al. [9]. Education is job and education level [19]. Nekoubi recognized as an important factor in health Moghaddam et al. found a relationship literacy. In order to minimize the impact of between education level and health literacy various factors including education affecting [20]. Koshyar et al. expressed a reversal health literacy, a health system should be meaningful relationship between health designed for people with low levels of literacy literacy and age and a direct and significant using simple illustrations and cultural relationship with family income. Also health examples through the media. Establishing literacy had a meaningful relationship with simple communication and easy instructions the level of education and occupation [21]. Amir can raise the understanding of health Esmaili et al., in his study entitled "Health information [34]. In some studies in other parts literacy level of pregnant women referring to of the world, there was no significant health centers", indicated that health literacy correlation between age and level of health had a significant relationship with age, literacy [35-37], which is confirmed by the education, abortion and number of children results of this study. It is worth noting that [22]. Reissi et al. also related health literacy to regardless of the effect of different factors on age, education level and household income [23]. health literacy and the effect of some of them, Anderson found a relationship between health in particular education, on the other variables, literacy and social-economic status of housewives living in rural areas, with weak or mothers. It had an impact on the care of the impoverished economies, are subject to the baby's life and health [24]. The target consequences of having low health literacy. In population of the above study included approaching this group, people should use pregnant women with gestational diabetes, appropriate and reliable educational methods which was different from the present study. [12]. In the study of the relationship between The majority of the mothers of our study had maternal health literacy and self-efficacy in a weak economic level, which is probably due pregnant women referring to health centers, to the high cost of services in the private there was a positive and significant sector. This finding confirms the studies of relationship between maternal health literacy Amir Ismaili [22] and Bakhshi [25]. Perhaps the and dietary self-efficacy based on Pearson’s reasons for the lack of consistency of the correlation coefficient. As a result, self-efficacy outcome of this study with some other similar improves the health literacy of pregnant studies could be the discrepancy between the mothers. However, there was no significant measurement tools, the method of relationship between the mother’s and implementation, the interview, the target father’s age with maternal health literacy and group, and the time and place of the study. In dietary self-efficacy. Ellen et al. (2006), in a the present study, there was a significant cross-sectional study of 124 mothers in Los difference between health literacy and living Angeles in 2014, found that mothers' self- place. Other studies also showed this efficacy was effective in protecting the health significant difference among the patients of mothers and their children [38]. In line with referring to the health centers of the city and this study, Peyman et al., in the study titled villages and emergency centers [12, 26-29]. "The relationship between health literacy and Family monthly income also had a meaningful self-efficacy in postpartum women," relationship with health literacy, which is introduced health literacy as an effective consistent with the study of Tall et al. [19], but factor in self-efficacy. In this cross-sectional Nekoi Moghadam et al.'s study did not show descriptive-analytical study, 120 mothers, this relationship [22]. The high level of health aged 20 to 35 years, with a child less than

Health Education and Health Promotion Winter 2018, Volume 6, Issue 1 www.SID.ir Archive of15 SID Kharrazi S.S. et al. three months were randomly selected from literacy that is a very important and vital the health centers in Mashhad. The data issue. They should improve this ability among collection tool was a physical self-efficacy different social classes. Therefore, although it questionnaire, a quick adult health literacy is essential to educate and provide questionnaire, and Tafla Health Literacy information in pregnancy, what is important Questionnaire. The results indicated that the is the level of understanding, awareness, and average level of health literacy was the ability to use this information in cases of 51.4±12.3%. 27.5% had good health literacy, necessity and risk. Therefore, there is a need 42.2% had borderline health literacy, and for comprehensive efforts to increase 30% had unfavorable health literacy. Mean maternal health literacy. Practical score of physical self-efficacy of the interventions to improve health literacy, such participating women was 84.3±41.4. Also as clear communication with mothers, use of 18.3% of participants had a high self-efficacy, intelligible and illustrated media, visual 47.5% had a moderate self-efficacy, and teaching aids, and creation of an enabling 34.2% had a low self-efficacy. There was a environment for questioning, can improve it. significant relationship between health Given the working hours of health centers, literacy, and female self-efficacy. Women with mothers or students had less chance of adequate health literacy were significantly participating in this study. Given that the more self-efficacious [39]. The reason for the present study is a cross-sectional study, it was uncertainty of some results can be the not possible to achieve causal relationships. difference in the measurement tools in both Among other constraints of the study, self- health literacy and self-efficacy variables as checking was the tool of study, which was well as the difference in location. In the study eliminated by the questioner. of Dumming et al., high health literacy scores predicted changes in self-efficacy [40]. Also, in Conclusion Raisi et al.’s study, functional health literacy There are the significant correlation between was the most important predictor of self- maternal health literacy and self-efficacy in efficacy of diabetic patients for self-care pregnant mothers. behaviors [41]. Oziren et al. showed that there was a significant relationship between health Acknowledgment: The present study was literacy, self-efficacy and physical activity [42]. the result of a Master's degree thesis in health Prenatal care is the proper implementation of education and health promotion at Mashhad the principles that are aimed at maintaining School of Public Health, Mashhad, Iran the health of the mother and the birth of a (project No. 922890, dated 17/10/1393), healthy baby [43]. approved by the Deputy of Research and Non-printed media are the only effective ways Technology of Mashhad University of Medical to deliver a health message to those who have Sciences. We thank the Vice-Chancellor for little practical literacy. These media may Research in Mashhad University of Medical include images and radio tapes. Even readily Sciences and all the participants in this study. readable patients prefer non-written Conflicts of interests: Non-declared materials such as illustrated books, Ethical permissions: This research was videotapes, audio tapes, or multimedia approved by IRCT: IRCT2017062928863N18 presentations. In order to increase the level of code. people's health literacy, using approaches Authors’ Contribution: Authors’ such as streamlining information can be contribution has not been reported helpful, but experience has shown that separately. besides these, the use of communication Funding/ Support: The financial sources strategies and getting assistance from health education professionals to plan and design of this study have been provided by useful and effective programs tailored to the Mashhad University of Medical Sciences. target groups and their skill levels are effective. The practitioners should choose the References best educational approach to be able to make 1- Gaur RC. Environmental engineering laboratory the best improvement in the level of health manual for first year engineering students. 1st edition.

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